Monday, June 26, 2006

Healthy skepticism on the quality movement by a hospitalist thought leader

Robert Wachter, one of the originators of the term hospitalist, has a commentary on the quality movement in the June 21 issue of JAMA. He first focuses on accountability for “core measures” promulgated by CMS, JCAHO and others and concludes with speculation on how the quality and information revolutions will change the medical profession.

He suggests, with examples from his own institution (UCSF), that this new accountability has fostered a perfunctory approach to quality with unintended consequences such as patients inappropriately receiving multiple pneumococcal vaccinations or receiving inappropriate antibiotics for heart failure. Worse, this obsession with report cards (“playing for the test” as Wachter terms it) may divert attention away from more important aspects of quality which don’t happen to be the focus of the current report cards. I’ll go a step further and suggest that the quality movement as is now being played out publicly may be of little more than cosmetic importance.

While many of the core measures are of proven effectiveness (e.g. angiotensin converting enzyme inhibition for heart failure and aspirin for acute coronary syndrome) pneumococcal vaccination may be an exception. According to this Cochrane review the pneumococcal vaccine currently approved for adults is not effective in preventing pneumonia or mortality from pneumonia. Although it appears to have some ability to prevent bacteremia the NNTs for bacteremia and mortality from invasive pneumococcal disease are 20,000 and 50,000 respectively! In spite of this fact, pneumococcal vaccination is a major target for public report cards and pay for performance programs.

Wachter goes on to sound a cautionary note about electronic medical records and computerized physician order entry, reminding us of the Cedars-Sinai debacle, increased mortality in a pediatric population after implementation of CPOE and other examples of adverse consequences. He notes that the success stories of EMR and CPOE come from “institutions that built homegrown computer systems over decades and were staffed with physicians, researchers, and administrators who believed strongly in the value of the systems.”

While Wachter’s skepticism about the current state of the quality and information technology revolution is welcome his predictions concerning the eventual effect on the medical profession are chilling. Citing known practice variations and publicly reported quality breaches he asks “….can there be any doubt that central control of physicians' practice will need to be exercised, especially when there is evidence of substandard performance on publicly reported measures?” Speaking of computer systems which can “ruthlessly enforce rules and standards” he entertains hope that high quality of care can somehow be “electronically ensured.” It all sounds a bit Orwellian to me.

Wachter envisions medical practice becoming increasingly formulaic and rote with diminishing need for the “virtuoso diagnostician” of old. Those arts of medicine that survive the revolution, he suggests, might include procedures, counseling and care coordination. Maybe those clinical and basic science skills I’ve ranted about won’t be so important after all. Get ready for the new breed of physician: the Stepford doctor.